Medical Billing

Top Cardiology Billing Compliance Risks Providers Need to Know

Cardiology remains one of the more heavily scrutinized specialties in federal billing oversight, and 2026 brought a specific, significant development: an OIG report finding that roughly $105 million in Medicare Part B payments for office-based peripheral vascular procedures may represent medically unnecessary billing. Beyond that, cardiology’s recurring compliance risks center on diagnostic testing supervision requirements, documentation that doesn’t clearly support medical necessity, and modifier use on combined procedures. None of these risks are new in concept, but 2026’s specific findings and priorities make them more immediate. The OIG’s 2026 Peripheral Vascular Procedure Findings In May 2026, OIG published a report examining Medicare Part B billing for office-based peripheral vascular procedures, angioplasty, stenting, and atherectomy performed to treat peripheral artery disease. Medicare Part B paid over $1 billion for these procedures in 2022, and OIG found that physicians have increasingly shifted this work into office-based laboratories, where Medicare payments to physicians run higher than in other settings. Of the payments made to office-based laboratory physicians for these procedures, OIG identified approximately $105 million that may indicate billing for medically unnecessary services. This matters directly for interventional and vascular cardiology, since these are among the specialties that perform these specific procedures. OIG identified the flagged billing using claims-based measures, including unusually high rates of more invasive tibial procedures and a high average number of procedures per patient, and recommended that CMS follow up directly with the specific physicians it identified. As of September 10, 2026, CMS formally concurred with that recommendation, according to OIG’s own recommendations tracker, meaning it’s actively moving forward rather than sitting unaddressed. Both of OIG’s recommendations from this report remain open as of this writing, with CMS’s next update expected November 3, 2026. It’s worth noting the findings haven’t gone unanswered. In June 2026, several vascular and interventional specialty societies issued a joint statement responding to the report, agreeing on the need for appropriate, evidence-based PAD care while arguing that parts of the report’s methodology and clinical framing require more careful interpretation. That pushback doesn’t change the underlying billing patterns OIG identified, but it’s a reasonable reminder that being flagged by one of the claims-based measures isn’t the same as a confirmed finding of improper billing. Practices performing these procedures in an office-based setting should still treat this as a direct, active signal to review their own billing patterns against the measures OIG used, rather than assume the report doesn’t apply to them. Diagnostic Testing Supervision Requirements Cardiology relies heavily on diagnostic testing, stress tests, echocardiograms, nuclear cardiology studies, and each of these services has its own physician supervision level requirement under Medicare rules. Billing a diagnostic test without the documentation to support that the required supervision level was actually met, whether that’s general, direct, or personal supervision depending on the specific test, is a recurring compliance exposure that’s distinct from a simple coding error, since it goes to whether the service was furnished in compliance with the conditions for payment at all, not just whether it was coded correctly. Modifier 25 and the Broader 2026 OIG Focus Modifier 25 remains a named federal priority for 2026, with OIG examining E/M claims billed alongside minor procedures where documentation needs to clearly support a significant, separately identifiable evaluation. This applies across specialties, but it’s a particularly common pattern in cardiology, where a diagnostic procedure and an E/M evaluation frequently happen in the same visit. The compliance risk isn’t using modifier 25 itself; it’s using it on a visit where the note doesn’t actually distinguish the separate evaluation from the routine work already built into the procedure. Documentation That Doesn’t Clearly Support Medical Necessity A recurring theme across cardiology audit findings, from the peripheral vascular report to general OIG and payer reviews, is documentation that doesn’t clearly establish why a specific procedure was medically necessary for that specific patient. For procedures like peripheral vascular interventions, this increasingly means documenting that conservative management, medication optimization, supervised exercise therapy, and lifestyle modification, were attempted and considered before proceeding to an invasive procedure, not just documenting the diagnosis that justified it in general terms. A Quick Compliance Checklist Risk Area What to Confirm Peripheral vascular procedures in OBL settings Review billing patterns against OIG’s flagged measures; confirm conservative management was documented before intervention Diagnostic testing supervision Confirm the required supervision level was met and documented for each specific test type Modifier 25 on combined visits Confirm documentation clearly separates the E/M evaluation from routine procedure work Medical necessity documentation Confirm the note establishes necessity for this specific patient and procedure, not just a general diagnosis Internal audit cadence Review high-risk billing patterns regularly rather than waiting for an external audit to surface issues Conclusion Staying ahead of cardiology’s specific compliance risks depends on accurate coding and documentation review built into the billing workflow, not just a response after an audit arrives. Rapid RCM Solutions supports this through its coding and reporting services, helping cardiology practices review billing patterns and documentation before they draw the kind of attention OIG’s 2026 findings describe. FAQs

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Insurance Eligibility Verification in Internal Medicine: A Complete Guide

Medical Billing

What Standard Eligibility Verification Checks Most eligibility verification runs through the HIPAA-standard X12 270/271 transaction, an inquiry sent to the payer and a structured response returned confirming plan status, copay, deductible, and coverage details. At a baseline level, this confirms whether a patient’s coverage is active, what plan type they’re on, and general cost-sharing figures. For a lot of specialties, that baseline check is close to sufficient. For internal medicine, it’s usually just the starting point. Insurance eligibility verification in internal medicine goes beyond confirming a patient’s coverage is active. Because internal medicine visits frequently involve chronic disease management, preventive services, and care coordination billing, like Chronic Care Management, verification needs to confirm coverage for the specific service type being billed, not just general plan status. A patient can have perfectly active insurance and still have a visit denied because the service itself, a wellness visit billed as a physical, or a CCM claim missing a consent record, didn’t match what that coverage actually supports. Why Internal Medicine Needs a Deeper Check A single internal medicine visit routinely touches more than one billable category at once: a chronic condition follow-up, a preventive component, and maybe care coordination services layered on top. Each of those categories can have its own coverage rules, its own medical necessity criteria, and its own documentation requirements, which means a verification check that only confirms “is this patient covered” misses the more important question: is this specific service, for this specific reason, covered the way the practice is about to bill it. CCM-Specific Eligibility Requirements Chronic Care Management is the clearest example of why a deeper check matters, and it’s specific enough that CMS maintains its own eligibility criteria separate from general coverage verification. According to CMS’s own CCM guidance, eligible patients need two or more chronic conditions expected to last at least 12 months, or until the patient’s death, that place them at significant risk of death, acute exacerbation or decompensation, or functional decline. Beyond the clinical criteria, CMS requires the billing practitioner to obtain the patient’s consent, verbal or written, before CCM services begin, documented in the medical record, and to maintain a comprehensive electronic care plan. Only one practitioner can furnish and bill CCM for a patient during a calendar month, which means part of a thorough eligibility check includes confirming the patient isn’t already enrolled in CCM somewhere else. None of this shows up on a standard 270/271 coverage check. A patient can have fully active Medicare coverage and still generate a CCM denial if the consent documentation isn’t in place, or if the practice doesn’t catch that another provider already billed CCM for that patient that month. Eligibility verification for CCM is really a combination of confirming coverage and confirming the practice’s own internal documentation is ready to support the claim, not a single lookup. Catching the Wellness Visit Distinction Before the Visit A second internal-medicine-specific gap worth checking early is the difference between Medicare’s Annual Wellness Visit and a routine physical exam. These aren’t interchangeable, and Medicare doesn’t cover routine physicals under standard coverage. A patient scheduling what they call their “yearly checkup” might actually be due for an AWV, a routine physical their plan doesn’t cover the same way, or something else entirely, depending on when they last had one and what their specific plan includes. Catching this at scheduling or check-in, before the visit happens, prevents a documentation and coding mismatch that eligibility verification alone won’t resolve once the visit is already underway. A Practical Verification Workflow Putting this together, a thorough internal medicine eligibility check generally needs to confirm four things before a visit: that the patient’s general coverage is active and the plan details are current, that any specific service being billed, CCM, AWV, or another care management code, meets that program’s particular coverage and documentation criteria, that required consent or enrollment documentation already exists if the visit involves an ongoing program like CCM, and that referral or prior authorization requirements specific to the visit’s services are satisfied ahead of time rather than discovered after the claim is submitted. A Quick Reference Checklist Check Why It Matters for Internal Medicine Standard coverage and plan status Confirms the patient’s insurance is active and current Service-specific coverage A chronic care, preventive, or AWV service may have different coverage rules than general coverage status implies CCM qualifying conditions Confirms two or more chronic conditions meeting the 12-month or significant-risk criteria, not just a general chronic diagnosis CCM consent and care plan documentation Required before billing, and not captured by a standard eligibility check Single-practitioner CCM billing Confirms the patient isn’t already enrolled in CCM with another provider that month AWV vs. routine physical Catching the distinction before the visit prevents a downstream coding and coverage mismatch Conclusion Verifying eligibility accurately for internal medicine’s mix of chronic care, preventive, and care coordination services takes more than a single coverage lookup. Rapid RCM Solutions supports this through its eligibility and benefits verification and coding services, helping practices confirm both general coverage and the service-specific requirements that internal medicine billing depends on before a claim is ever submitted. FAQs

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Claim Scrubbing Techniques in Medical Billing: A Practical Guide

Medical Billing

Claim scrubbing is the review of a medical claim for errors before it goes to the payer. The review checks patient data, codes, modifiers, provider details, and payer rules, so mistakes get fixed before they turn into rejections or denials. Many practices use scrubbing software, and some add a manual review on top of it. This guide covers the claim scrubbing techniques billing teams use, the errors each one catches, and how to measure whether your process works. Why Claim Scrubbing Matters A claim with an error costs more than a clean one. It has to be corrected, resubmitted, and tracked again, and the payment is delayed in the meantime. If the error isn’t caught or the appeal window closes, the revenue may not be recovered. Claim scrubbing also depends on the difference between a rejection and a denial: Scrubbing is most effective against rejections and the denials that come from avoidable errors, like wrong codes, missing modifiers, and ineligible coverage. It can’t fix a service the payer doesn’t cover. 8 Claim Scrubbing Techniques 1. Verify patient demographics and insurance details Check that the patient’s name, date of birth, subscriber ID, group number, and payer ID match the insurance card on file. A misspelled name or a transposed digit in the member ID is among the most basic reasons for a front-end rejection, and also one of the easiest to prevent. 2. Confirm eligibility before submission Run an eligibility check (the 270/271 electronic transaction) before the visit, and again before billing if time has passed or the patient’s coverage may have changed. Look for active coverage on the date of service, the correct plan, and whether the patient has a secondary payer. Claims sent to a terminated or incorrect plan are denied for eligibility. 3. Validate procedure and diagnosis codes Confirm that every CPT, HCPCS, and ICD-10-CM code is valid for the date of service. Codes are added, revised, and deleted on a regular schedule, so a code that was valid last year may not be now. Check that diagnosis codes are reported to the highest level of specificity, because payers reject claims with truncated or non-billable ICD-10-CM codes. 4. Check that diagnoses support the procedures billed Each billed service should be linked to a diagnosis that supports medical necessity. For Medicare, this includes Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs), which list the diagnoses that support certain services. Many commercial payers publish similar medical policies. A scrubber with these rules loaded can flag a mismatch before the claim leaves your system. 5. Review modifiers Modifiers change how a payer interprets a code, so wrong or missing ones are a common source of denials. Check that modifiers like 25, 59, LT/RT, and the X-modifiers (XE, XS, XP, XU) are used only when documentation supports them. Check also that the payer accepts the modifier for that code. Modifier 59 in particular is often reviewed by payers, so it should never be added just to get a claim past an edit. 6. Apply NCCI edits and MUEs The National Correct Coding Initiative (NCCI), run by CMS, includes procedure-to-procedure (PTP) edits that identify code pairs that generally shouldn’t be billed together and Medically Unlikely Edits (MUEs) that set the maximum units of a service per patient per day. Medicare and Medicaid use these edits, and many commercial payers apply similar logic. Scrubbers that include current NCCI tables will catch unbundling and excess units. 7. Check payer-specific rules Each payer sets their own claims requirements. This may include variations in how provider fields, taxonomy codes, place of service codes, and attachment requirements are rendered vs. billed. Review the NPI for every claim and ensure that the provider is registered with that particular payer. A claim that is valid by general coding rules may still be rejected due to the rules of one particular payer. 8. Verify authorizations and timely filing limits When a prior authorization is required by the payer, confirm that the authorization was obtained and that the authorization number on the claim is the same as the approved service, dates, and units. Also check the filing deadline. Medicare, for example, generally requires claims to be filed within 12 months of the date of service, and commercial payers often set shorter limits, which are stated in the provider contract. A claim filed after the deadline is typically denied, and the denial is rarely overturned. Manual vs. Automated Claim Scrubbing Automated scrubbing runs every claim through a set of rules in seconds. It can process large volumes and shows consistent errors like incorrect codes, missing fields, NCCI conflicts, and mismatching payer IDs. Its limit is that it only checks what it has been configured to check, so the rules must be updated when payers or code sets change. Manual review is slower, but a trained coder can catch problems software misses, such as documentation that doesn’t support the level of service billed, or a diagnosis that doesn’t fit the clinical picture. Most practices get the best results by scrubbing every claim automatically and reviewing high-dollar, high-risk, or frequently denied claims by hand. Common Errors Scrubbing Catches How to Measure Your Scrubbing Process Two metrics show whether your process works: Clean claim rate: the percentage of claims that are free of errors when they are submitted. A claim is clean if it can be processed without being rejected or needing correction. First-pass acceptance rate: claims accepted by the payer on the first submission, divided by total claims submitted, multiplied by 100. Track both by payer and by error type. If one payer rejects far more claims than the others, the cause is usually a specific rule your scrubber doesn’t have yet. Best Practices Get Support With Claim Scrubbing and Denial Management A scrubber only works as well as the rules behind it and the people who act on its reports. For many practices, keeping rule sets current, working rejection queues, and tracing denials back to their cause takes more staff time than

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What Is a Contractual Adjustment in Medical Billing?

Medical Billing

A contractual adjustment in medical billing is the portion of a provider’s billed charge that the provider agrees, under a payer contract, not to collect. On a straightforward in-network claim, it is the difference between the billed charge and the allowed amount. When a payer reports it as a contractual obligation, the amount is the provider’s responsibility and generally can’t be billed to the patient. If you work in a billing office, you’ll see contractual adjustments frequently on in-network claims. Here’s how they work, how to calculate them, and where practices most often go wrong. Why Contractual Adjustments Happen Many practices set their standard charges above what they expect to receive from contracted payers. When a practice joins an insurance network, its contract specifies how covered services are reimbursed, usually through a fee schedule or another agreed payment method. That contracted amount determines the allowed amount for a claim. The provider agrees to the terms of reimbursement from the payer in exchange for access to the payer’s members. A contractual adjustment is the difference between the billed charge and the allowed amount. Medicare operates on the same principle but with some differences. The participating provider agrees to accept the assignment, which is defined as accepting the Medicare allowable amount as full payment, along with the patient’s deductible and applicable coinsurance. Amounts the provider can’t collect from the patient may be reported as contractual obligations. Nonparticipating providers follow different Medicare billing rules, including limiting charges for certain services. The Contractual Adjustment Formula For a straightforward in-network claim: Contractual Adjustment = Billed Charge − Allowed Amount Use the allowed amount reported on the payer’s remittance, preferably the electronic remittance advice (ERA) when available. Don’t rely on a fee schedule you saved two years ago, because payers update rates and your system may be out of date. Contractual Adjustment Example Say a patient sees an in-network provider for a visit with a $30 copay. Item Amount Billed charge $200 Allowed amount $120 Contractual adjustment $80 Patient copay $30 Payer payment $90 The practice submits a $200 charge, and the payer allows $120. The $80 difference comes off the account. The patient pays $30, and the payer pays $90, which together equal the $120 allowed amount. The balance is zero. Now suppose the patient hasn’t met their deductible. The payer pays $0, and the patient owes the full $120. The contractual adjustment is still $80. It comes from the contract, not from how the allowed amount is split between the patient and the payer. How It Appears on an ERA Payers report adjustments using a group code and a Claim Adjustment Reason Code (CARC). The ERA is the main source billing teams use for posting, while the EOB is the patient-facing version. CO-45 is a common code combination for a contractual adjustment. The group code is as important as the reason code, as it defines the financial responsibility. Amounts assigned to PR (Patient Responsibility), such as deductibles, coinsurance, and copays, generally represent what can be billed to the patient, subject to payer and regulatory rules. Contractual Adjustment vs. Write-Off vs. Denial People mix these up, and the mistake costs money. Contractual adjustment: a reduction required by the payer contract or applicable regulation. The provider can’t collect it from anyone. Write-off: an amount removed from accounts receivable (A/R). There’s an adjustment type called contractual. Examples are bad debt, charity care, and courtesy adjustments, depending on the rules and practice policies. Denial: refusal by the payer to pay (in part or in full) for goods or services. Common issues include lack of information, eligibility issues, and lack of medical necessity. Many denials can be fixed with a corrected claim or an appeal. If a denied claim gets posted as a contractual adjustment, the balance can disappear from A/R without anyone pursuing money that may be recoverable. Why Contractual Adjustments Matter for Your Revenue Cycle Your A/R stays accurate. If contractual adjustments aren’t posted correctly, A/R can include amounts the practice isn’t entitled to collect, which makes the balance look higher than it should. Your key numbers stay reliable. Accurate adjustment posting matters for metrics like net collection rate and days in A/R. Gross charges show what you billed, not what you can expect to earn. You can catch underpayments. Compare the allowed amount on each remittance to your contracted rate. If a payer allows $110 for a service your contract reimburses at $120 under the same circumstances, the $10 difference may be an underpayment, not a contractual adjustment. You stay compliant. Billing a patient for an amount assigned to CO on an in-network claim can violate your payer agreement and applicable billing rules. For Medicare, billing an amount assigned to provider responsibility can also violate Medicare requirements. Common Mistakes to Avoid Balance billing in-network patients. Amounts assigned to PR generally represent patient responsibility. Sending a statement for a CO-45 amount is a contract problem and a source of patient complaints. Posting adjustments by hand without checking. Typing in numbers invites errors. Verify each adjustment against the ERA or other remittance information. Using outdated reimbursement data. When the rates or terms in your system don’t match the payer’s current contract, your expected reimbursement is wrong and underpayments go unnoticed. Accepting every allowed amount as correct. If you never compare what the payer allowed to your contract, you won’t find out when they pay less than agreed. Using one adjustment code for everything. Contractual adjustments, denials, bad debt, and charity care should have separate codes. When they’re lumped together, your reports can’t show where revenue is going. Best Practices for Posting Contractual Adjustments Get Help With Payment Posting and A/R Contractual adjustments look simple, but small posting errors add up across thousands of claims. Wrong adjustments, missed underpayments, and denials coded as write-offs quietly cut into a practice’s collections. Rapid RCM Solutions is a medical billing and revenue cycle management company that helps practices post payments accurately, follow up on unpaid claims, and manage denials. If your

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ERA vs. EOB in Medical Billing: What’s the Difference?

Medical Billing

Electronic Remittance Advice (ERA) and Explanation of Benefits (EOB) are both related to the same claim adjudication outcome, but not in the same format. The ERA, formally known as the ANSI ASC X12N 835, is an electronic transaction sent to the provider’s billing system to use for automated payment posting. An EOB is a statement provided to the patient that explains how the health plan processed a claim, including charges, covered amounts, payments, and what the patient may owe. The ERA is coded with Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), and Claim Adjustment Group Codes to explain adjustments, while the EOB may contain related information, but the coding detail and layout may change depending on the payer. What Each Document Actually Is The ERA is the electronic remittance advice a payer sends to a healthcare provider after a claim has been adjudicated. It uses the ASC X12N 835 transaction standard adopted under HIPAA for electronic remittance advice. Because it’s structured, machine-readable data rather than a formatted document, a properly configured billing system can import the ERA and automate the posting of payments, adjustments, and claim-related information, reducing manual data entry. An EOB is a patient-facing explanation of how a health plan processed a claim. It can show the billed amount, allowed or covered amount, plan payment, and the amount the patient may owe. An EOB is not a bill. For provider-side payment posting, the ERA is generally the more useful source because it’s a standardized electronic transaction designed for automated processing. The Codes Behind Both Documents This is the part that gets skipped in most explanations of ERA versus EOB, but it’s genuinely the mechanism that makes the ERA work. Adjustments reported on an ERA are explained using standardized codes rather than proprietary, payer-specific language. These include CARCs, RARCs, and Claim Adjustment Group Codes. Claim Adjustment Reason Codes (CARCs): These codes provide information to help explain why a claim was adjusted, including any reduction, denial, or other change from the billed amount. CMS states that the Medicare Policy requires CARCs in the remittance advice and coordination of benefits transactions and that the code set is administered by the Claim Adjustment Status and Reason Code Maintenance Committee (X12). Remittance Advice Remark Codes (RARCs) provide additional information alongside CARCs when more detail is needed to explain an adjustment or adjudication result. CMS is the national maintainer of the RARC list, published through the Washington Publishing Company. Claim Adjustment Group Codes identify the general category of financial responsibility associated with an adjustment. Common group codes include CO (Contractual Obligation), PR (Patient Responsibility), OA (Other Adjustment), PI (Payer-Initiated Reduction), and CR (Corrections and Reversals). CO generally assigns financial responsibility to the provider, and PR identifies amounts that can be charged to the patient/insured. A CARC is used in conjunction with a group code to convey both why the adjustment is being made and the financial responsibility. CARC and RARC code sets are formally reviewed and updated regularly. CMS recommends that the current valid code sets be utilized and not the older versions. Same Claim, Different Communications Picture one office visit that gets billed and adjudicated. The health plan records the claim determination and communicates the result differently to the provider and the patient. The provider can receive an ERA containing structured payment and adjustment information, including applicable group codes, CARCs, and RARCs. The patient may receive an EOB that explains the claim outcome, covered amounts, plan payment, and potential patient responsibility in a more readable format. The two communications relate to the same claim-processing outcome, but they serve different purposes and aren’t necessarily identical documents, one built for automated processing, one built for a person trying to understand their bill. Why the Distinction Matters Operationally When available and properly configured, the ERA allows billing teams to automate payment and adjustment posting instead of manually entering information from a paper or PDF remittance document. The ERA is generally the more structured source for provider-side payment posting because it uses standardized electronic transaction fields and adjustment codes, while a payer’s EOB layout and how clearly it displays claim information can vary considerably from one payer to another. Using a patient-facing EOB as the primary source for provider-side payment posting can introduce unnecessary manual work and increase the risk of posting errors. A Quick Reference Checklist Element ERA EOB Audience Healthcare provider/billing system Patient or health plan member Format Structured electronic transaction (ASC X12N 835) Patient-facing statement; format varies by payer Primary use Provider-side payment and adjustment processing Explaining how the claim was processed and what the patient may owe Adjustment information Uses standardized group codes, CARCs, and RARCs Presents claim/payment information in a patient-readable format; coding detail varies Payment posting Preferred source for provider-side automated posting Not generally the preferred source for provider-side payment posting Conclusion Accurate payment posting is easier when billing teams use the ERA’s structured payment and adjustment information rather than relying primarily on patient-facing EOBs. Rapid RCM Solutions supports this through its coding, reporting, and AR and denial management services, helping practices post payments accurately and identify adjustment codes that require follow-up, helping reduce avoidable revenue leakage. FAQs

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How Often Should AR Follow-Up in Medical Billing?

Medical Billing

AR follow-up should become more intensive as claims age, but there isn’t one universal follow-up schedule for every practice or payer. A practical approach is to review AR aging regularly, monitor newer claims for exceptions, actively work unresolved claims as they enter older aging buckets, and give immediate attention to claims approaching payer-specific timely filing or appeal deadlines. MGMA tracks AR using 0-30, 31-60, 61-90, 91-120, and 120+ day buckets, while HFMA publishes AR performance benchmarks practices can use alongside their own payer mix and specialty data. What AR Benchmarks Mean for Follow-Up Frequency Follow-up cadence isn’t an arbitrary schedule. It’s built around a specific target: keeping the practice’s overall accounts receivable inside a defined, healthy range. HFMA’s published KPI guidance identifies 30 to 40 days in AR as a target range and recommends keeping AR over 90 days below 10% of total receivables, with self-pay AR over 90 days kept below 30%. MGMA maintains its own benchmarking data, including an AR aging dashboard that breaks receivables into standard buckets, 0-30, 31-60, 61-90, 91-120, and over 120 days, to help practices analyze their own aging distribution and compare performance with relevant MGMA benchmarks. Those targets are the reason follow-up frequency isn’t flat across a claim’s lifecycle. A claim sitting at 15 days old doesn’t generally carry the same urgency as one at 75 days. Older AR contributes more heavily to aging metrics and may have fewer remaining options as payer filing and appeal deadlines approach. Recommended Cadence by Aging Bucket Exact timing varies by practice, payer, and claim type. The following is a practical framework for structuring follow-up rather than a universal industry standard: 0-30 days: Claims in this range may still be in the payer’s normal claim processing window, depending on the claim type and the payer. The aging report is viewable regularly, and for rejected claims, unusual status changes, high-dollar claims, and others, action is taken earlier. 31-60 days: This is the right time to start more vigorous follow-up of unclosed claims. If there is a claim, check if the claim was received by the payer and the claim status, and if there is a rejection/denial/pend reason, check for it before the balance moves to an older bucket. Depending on the turnaround times of payers and the availability of staff, there is an option for following up within one to two weeks after entry into this bucket. 61-90 days: Claims at this stage are considered materially older AR and should be given priority follow-up since they may have fewer days to address payer issues prior to filing or appeal deadlines. 90+ days: Claims this old generally warrant high-priority attention, particularly when a payer deadline, denial, appeal, or documentation issue is unresolved. MGMA’s benchmarking material specifically tracks 120+ day AR as an important indicator, and better-performing practices tend to carry less AR in that oldest bucket. Underneath this age-based structure, claims approaching a payer’s specific timely filing deadline need same-day attention regardless of where they otherwise sit in the aging schedule. Missing a payer’s timely filing deadline can make a claim ineligible for payment or significantly limit the options for recovering the balance, depending on the payer’s rules and applicable exceptions. Age Isn’t the Only Variable Worth Weighing Strict aging-based cadence is a reasonable default, but it isn’t the whole picture. A $50 claim sitting at 40 days and a $4,000 claim sitting at 40 days don’t carry the same urgency, even though they’re the same age, and a practice may reasonably weight follow-up priority by dollar value as well as age for exactly that reason. Denials and underpayments also call for different handling even at the same age. A denied claim generally requires the underlying reason to be addressed and may require an appeal. An underpayment, where the amount paid is less than what the practice expected under the applicable contract or reimbursement terms, requires a separate payment review comparing the payer’s reimbursement with the applicable contract, fee schedule, or expected allowed amount. Daily, Weekly, and Monthly Review Serve Different Purposes Follow-up cadence and reporting cadence aren’t quite the same thing, and conflating them is a common source of confusion. MGMA recommends tracking revenue-cycle KPIs at least monthly for administrative leaders, with more frequent review for billing staff working claims day to day. A practice can use that more frequent, claim-level review to identify balances that need action before they move into older aging buckets, while reserving the monthly cadence for assessing whether overall days in AR and the percentage of AR over 90 days are staying inside target range. A practice can have strong claim-level follow-up day to day and still miss a slow drift in its overall AR metrics if nobody’s reviewing the aggregate numbers on a regular schedule too. A Quick Reference Checklist Aging Bucket Suggested Follow-Up Approach 0-30 days Review regularly; monitor for rejections, unusual status, or other exceptions 31-60 days Increase active follow-up on unresolved claims 61-90 days Prioritize unresolved claims and investigate outstanding payer issues 90+ days High-priority follow-up, especially where deadlines or unresolved denials are involved Approaching timely filing deadline Same-day action regardless of age bucket Overall AR performance Review at least monthly at the leadership level, more frequently for billing staff Conclusion Consistent AR follow-up depends on a structured cadence being applied every week, not just when someone has spare time between other tasks. Rapid RCM Solutions supports this through its AR and denial management services, helping practices work aging claims on a disciplined schedule and resolve denials and underpayments before they become more difficult or time-sensitive to recover. FAQs

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CDT vs. CPT vs. ICD-10 Codes Explained: A Complete Guide

Medical Billing

CDT, CPT, and ICD-10-CM are three separate code sets that serve different purposes and often, though not always, different claim forms. CDT codes describe dental procedures and are maintained by the American Dental Association. CPT codes describe medical procedures and are maintained by the American Medical Association. ICD-10-CM, the U.S. clinical modification of the World Health Organization’s ICD-10, describes diagnoses and reasons for healthcare services, maintained through the U.S. federal government, primarily the CDC’s National Center for Health Statistics, with CMS involved in implementation. A routine cleaning is typically reported with a CDT procedure code alone, though ICD-10-CM diagnosis codes can also be reported on dental claims when applicable. A procedure with a medical indication, such as trauma-related treatment, may instead be billed to medical insurance using the procedure and diagnosis coding required by that payer. Why the Distinction Matters A patient is fitted for an oral appliance to treat obstructive sleep apnea. A dentist provides and adjusts it, which looks like a dental procedure on the surface. But the appliance exists because of a diagnosed medical condition, not a dental one. That distinction can affect whether the service is billed to dental or medical insurance and which coding and claim-submission requirements apply. Submitting a medically related service as a routine dental claim without the coding or documentation a payer requires can result in rejection or denial, not because the treatment was inappropriate, but because the claim didn’t meet what that specific payer needed to see. These three code sets serve related but distinct functions, and using the wrong one, or omitting one that’s required, can contribute to avoidable claim rejections or denials. The Three Code Sets CDT (Current Dental Terminology) is the code set for dental procedures, maintained by the American Dental Association. Each code begins with the letter D followed by four numbers. CDT codes can be reported on the ADA Dental Claim Form or the standard electronic dental claim transaction, 837D, and describe the procedure performed. CPT (Current Procedural Terminology) is a separate code set used to report medical procedures and services, maintained by the American Medical Association’s CPT Editorial Panel. Dentists may use CPT codes when reporting certain services to medical payers, depending on the procedure and payer requirements. ICD-10-CM codes describe a patient’s diagnosis or condition rather than a procedure, and can support the medical necessity of a reported service. They’re the U.S. clinical modification of the World Health Organization’s ICD-10, maintained through the U.S. federal government, primarily the CDC’s National Center for Health Statistics, with CMS involved in implementation. Medical claims generally require an appropriate diagnosis code, subject to payer and claim-specific requirements. Dental claims commonly use CDT procedure codes, and ICD-10-CM diagnosis codes may also be reported when applicable, since both CDT and ICD-10-CM are HIPAA standards applicable to electronic dental claims. The ADA Dental Claim Form itself includes fields for up to four diagnosis codes, and some payers, including certain Medicaid programs, require them. All three code sets update on their own schedules. The ADA releases CDT updates effective January 1 each year. CPT updates follow a similar annual cycle through the AMA. ICD-10-CM follows a federal fiscal-year update cycle, with annual October 1 updates and, when applicable, interim updates during the year. Using a code that wasn’t valid for the actual date of service can result in a claim error or rejection. Medical-Dental Cross-Coding Medical-dental cross-coding involves determining which procedure and diagnosis codes appropriately describe a dental service when medical and dental coding requirements overlap, including situations where a dental service may be submitted to a medical benefit. Examples that may involve cross-coding include certain oral appliances for sleep apnea, treatment following facial trauma or accidental injury, some TMJ-related services, oral-tissue biopsies, and certain frenectomies performed for newborn feeding difficulties. For these situations, the procedure may be coded under a CDT or CPT code, depending on the payer/billing context, and an ICD-10-CM code may serve as a means to record a diagnosis/condition that underlies the service provided. The right codes are not always the same, but rely on the service, documentation, and payer requirements. CDT codes do not always have a “one-to-one” match with CPT codes, and the appropriate crosswalk may be more dependent on clinical context and documentation. Most dental claims are done on the standard ADA Dental Claim Form, which is intended to report dental procedures with CDT codes, and most medical professional claims are made on the CMS-1500 or electronic equivalent claim form. A provider should not assume that a medical benefit is always the first benefit through which to bill a service, but should check the payer’s requirements before filing. Example: How the Codes Apply Together A patient sustains a dental injury from a fall and requires repair. The claim includes the appropriate ICD-10-CM diagnosis code or codes describing the injury and other relevant conditions, sequenced according to the applicable claim and payer requirements. The procedure is then reported using the code set required by the claim destination and payer: a dental claim may use the appropriate CDT code, while a medical claim may require CPT or, in some circumstances, an appropriate CDT code, along with the diagnosis coding that payer requires. An omitted or inaccurate diagnosis code can prevent the payer from properly evaluating the clinical reason for the service and may contribute to a rejection or denial. Common Errors in Cross-Coding Several errors can contribute to cross-coding rejections or denials, including: submitting a CPT code where the payer’s dental claim process doesn’t accommodate it; billing an outdated CDT or CPT code version that doesn’t match the date of service; submitting a medical claim without a supporting ICD-10-CM diagnosis code, which medical payers generally require to establish necessity; and assuming that any dental procedure with some medical relevance automatically qualifies for medical billing, when the documentation must clearly support genuine medical necessity for that specific payer. Quick Reference Code Set Maintained By Used For Typical Claim Form/Transaction CDT American Dental Association Dental procedures ADA Dental

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How to Improve Internal Medicine Denial Management in 2026

Medical Billing

Internal medicine denials rarely look like a coding mistake on the surface. A physician manages three chronic conditions in one visit, adjusts medication, reviews recent labs, and documents all of it accurately, and the claim still comes back denied because the note doesn’t clearly support the E/M level billed, or a chronic care management claim gets rejected because the required patient consent wasn’t logged in a way the payer could verify. The service may have been clinically appropriate, but the documentation didn’t support it in the way the payer required. Improving internal medicine denial management in 2026 means identifying the specific patterns driving a practice’s denials, including documentation gaps, coding issues, eligibility or authorization problems, and payer-specific requirements. The most effective fixes are categorizing denials by cause rather than just reworking them one at a time, tightening MDM and CCM documentation habits, and tracking whether specific denial patterns actually decline after a fix rather than just measuring how many claims got resubmitted. Why Internal Medicine Denials Look Different From Other Specialties Internal medicine practices commonly rely heavily on evaluation and management (E/M) services, along with chronic care management and preventive services, rather than a high volume of procedures. This mix can create denial risks around the level of E/M service reported, documentation supporting the medical decision-making, chronic care management requirements, modifier 25 use, and diagnosis-code specificity. The Denial Drivers Worth Prioritizing First Several categories are worth monitoring closely in internal medicine practices. Medical decision-making documentation that doesn’t clearly support the E/M level billed is a common one, since MDM depends on the number and complexity of problems addressed, the data reviewed, and the risk involved, and a note that lists conditions without adequately documenting the medical decision-making for that encounter may not support the E/M level reported. Chronic care management billing is another significant category, since Medicare CCM requires two or more chronic conditions expected to last at least 12 months or until the patient’s death, along with applicable care-plan, consent, and time requirements that vary by the specific CCM code billed, and missing a required element can result in nonpayment or denial even when related care was provided. Modifier 25 errors, when a significant, separately identifiable problem-oriented E/M service is reported alongside a preventive service or another procedure on the same day, and unspecified ICD-10 codes used where the documentation actually supports more specificity, round out the categories worth watching. What Changed for 2026: Faster Decisions, Specific Reasons For internal medicine practices working with Medicare Advantage, Medicaid, CHIP, and certain marketplace plans, 2026 brought a significant regulatory shift in prior authorization. CMS’s Interoperability and Prior Authorization Final Rule requires impacted payers to provide a specific reason when denying a prior authorization request for medical items and services, excluding drugs, rather than a generic code. For applicable payers, decisions generally must be provided within 72 hours for expedited requests and seven calendar days for standard requests, though it’s worth being precise here: the decision-timeframe requirements specifically exclude Qualified Health Plan issuers on the federally facilitated exchanges, even though those issuers are still subject to the rule’s other provisions, including the specific denial-reason requirement and public reporting. The American College of Physicians has been advocating for exactly this kind of reform through its Patients Before Paperwork initiative for years, arguing that prior authorization delays and vague denial reasons create unnecessary administrative burden. For internal medicine practices specifically, the more specific denial reasons required under the new rule matter operationally: a structured reason gives staff something concrete to act on for resubmission or appeal, rather than a generic reason that may require additional payer communication to determine what needs to change. Building a Process, Not Just Reworking Claims Reworking each denial as it comes in may help recover individual claims, but it doesn’t necessarily reduce how often the same denial happens again. A more effective approach starts with categorizing every denial by reason code, payer, and the specific point in the workflow where it originated, MDM documentation, CCM criteria, modifier use, or coding specificity. That categorization can turn a stack of individual denials into a smaller number of recurring patterns worth investigating and fixing. From there, the fix usually isn’t more coder training alone. MDM documentation gaps often trace back to how a physician’s note is structured during the visit itself, not how the coder interprets it afterward, so addressing the pattern may mean adjusting documentation templates or physician workflows rather than just the billing process. CCM denials often trace back to how consent and time are logged during the month, which is a clinical staff workflow issue as much as a billing one. Involving the right people in addressing the underlying cause, rather than relying solely on the billing team to rework the claim, makes the corrective action more sustainable. A Quick Improvement Checklist Area What to Do MDM documentation Confirm notes support the medical decision-making for the conditions addressed during the encounter, rather than relying on a problem list alone CCM billing Verify qualifying conditions, applicable care-plan and consent requirements, and the required monthly time before submitting Modifier 25 Use a consistent review for visits where a problem-oriented E/M service is reported with another service on the same day, confirming modifier 25 requirements are met ICD-10 specificity Flag unspecified codes for review when the documentation actually supports a more specific diagnosis Denial categorization Log every denial by reason, payer, and workflow origin point, not just resubmit and move on Prior authorization tracking Confirm which payers are subject to the 2026 CMS timelines and track whether decisions are actually meeting them Conclusion Consistent improvement in internal medicine denial management depends on accurate coding, careful eligibility and authorization tracking, and reporting that shows which denial patterns keep recurring. Rapid RCM Solutions supports practices through coding, eligibility and benefits verification, accounts receivable (AR), and denial management services, helping them identify recurring denial patterns and address the workflow issues behind them rather than simply resubmitting the same claims.

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Root Cause Denial Analysis: A Complete Guide for Healthcare Providers

Medical Billing

A billing team reworks forty denied claims in a week and successfully overturns thirty of them. On a productivity dashboard, that looks like a strong week. But if twenty-five of those thirty denials trace back to the same missing modifier or the same eligibility check that keeps getting skipped, the team spent real labor fixing a symptom while the actual defect in the workflow stayed untouched, ready to generate the same denial again next month. That gap, between working a denial and actually eliminating its cause, is what root cause denial analysis is built to close. Root cause denial analysis is the process of tracing a denied claim back to the underlying process or operational issue that contributed to it, such as an eligibility gap, a missing authorization, or a documentation shortfall, rather than simply correcting and resubmitting the claim. Denial management addresses the individual claim. Root cause analysis addresses the underlying workflow so future claims are less likely to be denied for the same reason. The distinction matters because recurring denials can consume significant staff time and leave preventable revenue at risk, particularly when the underlying workflow issue is never actually addressed. Root Cause Analysis Is Not the Same Thing as Denial Management Denial management is the broader function: identifying denied claims, correcting them, and either resubmitting or appealing. It’s necessary, and most revenue cycle teams already do some version of it. Root cause analysis is a specific discipline within that function, one that asks a different question. Instead of “how do we get this claim paid,” it asks “why did this happen, and what has to change so it stops happening?” The methodology draws from root cause analysis as practiced in patient safety and quality improvement, where recurring problems are often examined as system or process issues rather than being attributed solely to one person’s mistake. Applied to denials, that means looking past the individual claim and examining the upstream process, for example, where eligibility wasn’t checked, or where a documentation template failed to prompt for information a specific payer actually requires. Why This Matters More in 2026 Denials remain one of the most significant sources of revenue leakage practices face. In a January 2026 MGMA Stat poll of medical group leaders, 48 percent identified denials and appeals as their practice’s single biggest revenue cycle leak, well ahead of front-end issues, billing and collections, and coding. It’s worth being precise about what different data sources actually measure. KFF’s August 2026 analysis of insurer-reported 2025 prior authorization data, not overall claim denial rates, found that Medicare Advantage insurers denied 12 percent of standard prior authorization requests, and among those denials that were appealed, 67 percent were overturned. Medicaid managed care insurers denied 14 percent of standard requests, with 47 percent of appealed denials overturned, while ACA Marketplace insurers denied 18 percent, with 43 percent overturned on appeal. Across all three markets, the same research consistently found that denials are rarely appealed to begin with. That combination highlights why practices need to understand not just how often denials occur, but why, and whether the underlying process can actually be improved. Root cause analysis is what turns that question into an answer by identifying recurring documentation, authorization, eligibility, or workflow issues before they continue generating similar denials. How Root Cause Denial Analysis Actually Works The process starts with categorization, not correction. Every denied claim gets logged with its denial reason code, the payer, the service line, and the specific point in the revenue cycle where the breakdown occurred: registration, eligibility verification, prior authorization, coding, or documentation. That categorization is what turns forty individual denials into a pattern: not “forty different problems” but possibly three or four recurring failure points showing up across many claims. From there, the discipline is in resisting the urge to stop at the surface reason. A denial coded as “not medically necessary” might actually trace back to a documentation template that doesn’t capture the specific clinical criteria a particular payer requires, a problem that will keep generating denials until the template changes, not just until this one claim gets appealed. Getting to that deeper cause usually means pulling in more than just billing staff, since eligibility issues trace back to front desk workflows, documentation issues trace back to clinical staff and EHR templates, and authorization issues often trace back to scheduling. The last piece is measurement that actually reflects the goal. A team focused on denial management measures how many claims got reworked and how much revenue got recovered. A team doing root cause analysis also measures whether the same denial category is actually declining month over month, since a shrinking recurrence rate is the real signal that a fix worked, not just that this week’s claims got paid. Common Root Causes Worth Watching For A few categories show up repeatedly across most specialties and payers: eligibility and registration errors that surface only after a claim is submitted rather than before the visit, documentation that doesn’t align with a specific payer’s published clinical criteria, missing or expired prior authorizations, coding that doesn’t match the level of service actually documented, and timely filing issues caused by delays earlier in the workflow rather than the billing step itself. None of these are exotic. What varies by organization is which one is actually driving the largest share of denials, and that’s exactly what root cause categorization is meant to reveal rather than assume. A Quick Implementation Checklist Step What to Do Categorize every denial Log reason code, payer, service line, and the process stage where the breakdown occurred Look past the stated reason Trace surface-level denial reasons back to the upstream workflow failure that actually caused them Involve the right teams Pull in front desk, clinical, scheduling, and billing staff depending on where the root cause sits, not billing alone Track recurrence, not just recovery Measure whether a denial category is actually declining after a fix, not just how much was collected this week Prioritize by volume and value

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Family Practice Reimbursement Model: A Complete Guide for 2026

Medical Billing

A family physician and a colleague across town run nearly identical practices this year, similar patient panels, similar visit volume, similar mix of E/M and chronic care billing. One of them practices under an Advanced APM through an accountable care organization, and meets the specific participation thresholds to qualify as a Qualifying APM Participant, or QP. The other doesn’t. Since January 1, 2026, those two clinicians have been paid using different Medicare Physician Fee Schedule conversion factors. That’s not a hypothetical; it’s part of the payment structure CMS finalized for this year, and it’s one of the most important changes family practices need to understand about their reimbursement model right now. A family practice reimbursement model is the combination of payment structures a practice bills under, typically some mix of fee-for-service, value-based arrangements, and care management add-ons. For 2026, the biggest structural change is that CMS split the Medicare conversion factor in two for the first time ever, one rate for clinicians who qualify as Qualifying APM Participants (QPs) and a lower rate for everyone else, which means two clinicians billing the same codes can now be reimbursed differently based on their QP status alone. What a Reimbursement Model Actually Means Most family practices aren’t paid under one clean system. They’re paid under a blend: fee-for-service billing for the bulk of office visits, layered with value-based components like quality bonuses or shared savings if they participate in an ACO, plus care management codes that pay for work done outside the visit itself, medication reviews, care coordination, chronic disease monitoring between appointments. Understanding your practice’s reimbursement model means understanding that blend, not just the base fee schedule. The 2026 Change That Matters Most: Two Conversion Factors The conversion factor is the dollar multiplier CMS applies to a service’s relative value units to produce an actual payment amount. Through 2025, the standard Medicare Physician Fee Schedule used a single conversion factor for most physician services. As required by statute, CMS implemented two separate standard conversion factors for 2026: $33.5675 for Qualifying APM Participants (QPs), and $33.4009 for clinicians who are not QPs. That’s a 3.77 percent increase for QPs and a 3.26 percent increase for non-QPs, both up from 2025’s $32.3465, according to the American Academy of Family Physicians’ summary of the final rule. The gap itself is small in percentage terms, but it’s a real structural shift. For the first time, whether an eligible clinician qualifies as a QP directly affects the conversion factor used for their Medicare Physician Fee Schedule services, not just their eligibility for a separate bonus program layered on top. It’s worth being precise here: participating in an ACO or clinically integrated network that operates as an Advanced APM doesn’t automatically make every clinician in it a QP. QP status is determined individually, based on meeting specific payment or patient-count thresholds through that Advanced APM during the applicable performance period. The Other Piece That Works in Family Practice’s Favor CMS also finalized a 2.5 percent efficiency adjustment that reduces work RVUs for applicable non-time-based services in 2026. That can reduce payment for services affected by the adjustment, particularly in specialties with a large share of procedural, non-time-based billing. But CMS excluded time-based services, including evaluation and management, care management, and behavioral health services, from that adjustment. Because family practices commonly bill substantial amounts of E/M and care management services, this exemption may be particularly relevant to a typical family practice’s 2026 reimbursement mix, arguably as important as the conversion factor split itself. On top of that, 2026 expands the G2211 add-on code, which recognizes the complexity of ongoing primary care relationships, to home and residence evaluation and management visits, and adds three new optional Advanced Primary Care Management (APCM) add-on codes, G0568, G0569, and G0570, for behavioral health integration and psychiatric collaborative care management services billed alongside an APCM base code. What This Means for Your Practice The practical question isn’t whether these changes exist; it’s which side of the split your eligible clinicians fall on, and whether that’s the result of a deliberate participation strategy or just the practice’s current status. A few things worth checking: A Few Honest Caveats Participating in an Advanced APM isn’t free or automatic. Depending on the model, it typically means taking on some form of financial risk, meeting specific quality reporting requirements, and restructuring at least part of how care is coordinated across a patient panel. For a smaller independent practice, the administrative lift of pursuing that participation, and the individual clinician threshold that comes with it, may not be worth the conversion factor gap, at least not on its own. This is a genuine tradeoff to evaluate, not an automatic win. Quick Reference Model Element 2026 Status QP conversion factor $33.5675, a 3.77% increase Non-QP conversion factor $33.4009, a 3.26% increase E/M and care management codes Generally exempt from the new efficiency adjustment as time-based services G2211 Expanded to home and residence E/M visits APCM add-on codes G0568-G0570, new for behavioral health integration and psychiatric collaborative care management Conclusion Accurately capturing these changes, reviewing G2211 and APCM billing, and correctly coding the services that qualify for efficiency adjustment exemptions are as much operational priorities as strategic ones. Rapid RCM Solutions supports practices through coding and reporting services designed to help ensure that 2026’s payment changes are accurately reflected in what gets billed and collected. You can learn more at rapidrcmsolutions.com. FAQs

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Prior Authorization Denial Prevention: A Complete Guide for Providers

Medical Billing

A physician orders a service that requires prior authorization. Staff submit the request, and two weeks later it comes back denied for a reason that, on closer inspection, could have been caught before it was ever sent: a missing chart note, a mismatch between the diagnosis code and the requested service, or a submission that didn’t address the specific clinical criteria this particular payer uses for this particular procedure. The request gets resubmitted, the timeline resets, and the patient’s care is delayed in the meantime. That cycle is largely preventable, and the fixes are less about clinical judgment than about process discipline: knowing what each payer actually requires before submitting, not after. Most prior authorization denials trace back to a handful of preventable issues: incomplete or missing clinical documentation, eligibility or coverage mismatches caught too late, submissions that don’t align with a payer’s specific clinical criteria, and confusion over which entity actually reviews the request when a payer delegates utilization management to a third-party vendor. Prevention comes down to catching these gaps before submission rather than fixing them after a denial arrives, and 2026 adds a new layer to this with CMS rules requiring faster decisions and more specific denial reasons for many, though not all, health plans. What Actually Causes Prior Authorization Denials The reasons behind most prior authorization denials fall into a few recurring categories. Incomplete or missing clinical documentation is one of the most common, where the chart notes submitted don’t fully support the medical necessity of the requested service according to that specific payer’s criteria. Eligibility and coverage mismatches are another, where a request is submitted before confirming the patient’s coverage is active or that the specific plan covers the requested service at all. Submissions that don’t align with a payer’s published clinical criteria are a third category, since many payers publish specific guidelines for when a service will be approved, and a request that doesn’t address those criteria point by point is more likely to come back denied regardless of whether the care itself was appropriate. A physician survey published by the American Medical Association in May 2026 found that physicians complete an average of 40 prior authorization requests per week, and roughly a third of physicians reported that their requests are often or always denied. That volume is exactly why process discipline matters more than trying to fix each denial individually after the fact. The CMS-0057-F Layer: Faster Decisions, Specific Reasons For 2026, the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) changed some of the rules around how impacted payers have to handle prior authorization. Beginning January 1, 2026, impacted payers, including Medicare Advantage organizations, Medicaid and CHIP fee-for-service and managed care plans, and Qualified Health Plan issuers on the federally facilitated exchanges, must provide a specific reason when denying a prior authorization request for non-drug medical services. For prior authorization decision timeframes, impacted payers other than QHP issuers on the federally facilitated exchanges must generally respond within 72 hours for expedited requests and seven calendar days for standard requests. It’s worth being precise about scope here, since this rule doesn’t apply to every plan a practice deals with. It doesn’t cover prescription drug prior authorizations under this particular rule, and commercial timelines outside the plans listed above remain governed by whatever that specific payer’s own policies or applicable state law require. A specific, structured denial reason from a covered plan gives a practice something concrete to act on, rather than a generic code that requires a phone call just to understand what would need to change on resubmission, but staff still need to verify which of their payers are actually subject to these requirements. Traditional Medicare Has Its Own New Layer: The WISeR Model A detail that’s easy to miss is that CMS-0057-F does not apply to traditional, original Medicare fee-for-service. Instead, CMS has been testing a separate prior authorization approach for traditional Medicare through the WISeR Model, which became active in 2026 for a defined set of high-cost, high-variation services, including procedures like epidural steroid injections, cervical fusion, and skin substitute applications. Practices billing traditional Medicare for services on this list need to track WISeR’s requirements separately from the CMS-0057-F rule, since the two operate under different frameworks covering different parts of the Medicare system. Denial or Pend? Knowing the Difference Changes the Response Not every unfavorable prior authorization response is a final denial. A pend generally means the payer needs additional information before making a decision, while a denial is a final negative determination. Both consume staff time, but they call for different responses: a pend usually just needs the missing piece submitted, while a denial may call for an appeal, a peer-to-peer review request, or a corrected resubmission depending on the specific reason given. Treating every unfavorable response as an automatic denial and resubmitting blindly, without addressing the specific reason given, tends to produce another denial rather than an approval. Watch for Delegated Utilization Management Many larger payers delegate prior authorization review for certain services to specialty utilization management vendors rather than reviewing the request internally. When that’s the case, an appeal or additional documentation typically needs to go to that vendor directly, using its own portal or fax process, rather than to the health plan itself. Sending a follow-up or appeal to the wrong entity because a practice didn’t realize the review was delegated is a common, avoidable source of delay that has nothing to do with the clinical merits of the request. A Quick Prevention Checklist Issue Prevention Habit Incomplete clinical documentation Confirm the submission addresses the payer’s specific published clinical criteria before sending, not just general medical necessity Eligibility or coverage mismatches Verify active coverage and plan-specific benefit inclusion before submitting the request Missing plan-specific criteria Check each payer’s current clinical policy for the specific service, since criteria vary by payer and can change Confusing a pend with a denial Read the response carefully to determine whether it requires additional information or a formal appeal

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Insurance Benefits Verification Automation: How It Works and Why It Matters

Medical Billing

A patient calls to schedule a visit two weeks out. In the manual process, a front office staff member may review coverage either at scheduling, shortly before the appointment, or the day of the appointment, typically using payer portals or calling the payer. If it is not timely verified, a lapsed policy or plan change may not be discovered until after the visit and/or a claim is rejected. Automated benefits verification is designed to catch those issues earlier, running coverage checks electronically at scheduling, before the appointment, or at another point defined by the practice’s workflow, so the practice and the patient both know where things stand before the visit happens rather than after. Insurance benefits verification automation reduces reliance on manual phone calls and payer portal lookups by using electronic eligibility and benefit inquiries, commonly based on the HIPAA-adopted ASC X12N 270/271 standard and governed by CAQH CORE operating rules, that can return eligibility, coverage, copay, deductible, and other benefit information in real time or near real time, depending on payer connectivity. It matters because eligibility and registration errors can contribute to claim denials and are often easier to address before the visit than after a claim has been submitted, when they can require additional staff time, patient outreach, claim correction, or follow-up. What Is Insurance Benefits Verification Automation? Insurance benefits verification automation is software that electronically checks a patient’s insurance coverage, plan status, and benefit details as reported by the payer, without a staff member manually calling the payer or logging into a separate portal for each plan. Instead of a phone call, the software sends a standardized electronic request to the payer and receives a structured response back, typically within seconds for real-time checks or as part of an overnight batch for scheduled appointments. The goal is to obtain much of the same eligibility and benefit information that staff might otherwise gather manually, retrieved automatically and consistently across every payer a practice works with. The Standards Behind It: X12 270/271 and CAQH CORE At the technical level, many automated eligibility verification systems rely on the ASC X12N 270/271 transaction set, the HIPAA-adopted standard for electronic health plan eligibility and benefit inquiries and responses. HHS adopted the current Version 5010 of this standard in January 2009, with the standard becoming effective January 1, 2012, and related eligibility operating rules becoming federally mandated January 1, 2013. The 270 is the eligibility inquiry a provider’s system sends out, asking a payer whether a specific patient’s coverage is active and what it includes. The 271 is the payer’s response, which can return eligibility status, financial information such as copays and deductibles, and benefit information in a standardized electronic format the practice’s system can read automatically. On top of the X12 standard itself, CAQH CORE (the Committee on Operating Rules for Information Exchange) maintains a set of operating rules specifically for eligibility and benefits transactions, covering things like required response formats, system availability, and how real-time versus batch inquiries should be handled. These operating rules were adopted by HHS as required business rules under federal law, meaning the electronic eligibility ecosystem isn’t just one technical standard but a layered set of federally recognized requirements that govern how consistently and completely a 271 response has to answer a 270 inquiry. Real-Time vs. Batch Verification Automation software can connect to this transaction pipeline directly or through a clearinghouse that routes requests across multiple payers, and generally runs checks in one of two ways. Real-time verification queries the payer the moment it’s triggered, such as when an appointment is booked or a patient checks in, and returns a response almost immediately. Batch verification runs a group of upcoming appointments through the same process overnight or on a set schedule, which is often more efficient for practices verifying a full day’s schedule at once rather than one patient at a time. Many practices use both: a batch run before a scheduled visit, with a real-time check available for same-day or walk-in patients. Why This Matters Beyond Saving Staff Time The time savings are real, but the bigger operational benefit can be identifying coverage problems before they lead to billing issues. Registration and eligibility errors, including a lapsed policy, an unknown plan change, or coverage that does not include a specific service, can contribute to claim denials. These denials can occur even when the underlying service was otherwise coded and documented appropriately. Catching them before the appointment gives staff an opportunity to resolve the issue earlier in the revenue cycle, through patient outreach or coverage correction before the visit rather than claim correction or follow-up after submission. There’s also a patient experience dimension that’s easy to overlook. A patient who has clearer information about their coverage and potential cost-sharing before the visit is in a better position to understand their financial responsibility, and a practice that can answer coverage questions immediately at check-in can reduce unexpected billing conversations after the visit. How Does This Connect to Broader CMS Interoperability Rules? CMS has also been working to promote FHIR-based APIs in addition to the existing X12 270/271 eligibility standard to enhance electronic health information exchange. The 2024 CMS Interoperability and Prior Authorization Final Rule further expands upon the 2020 CMS Interoperability and Patient Access Final Rule and adds more API requirements for some affected payers, including on provider access, payer-to-payer exchange, and prior authorization. The 2020 rule set forth new mandates for specific payers to make specified health information available to patients electronically via a standardized Patient Access API. In addition to the emphasis on prior authorization, the rule includes new interoperability obligations that rely on new FHIR-based APIs for some impacted payers, part of a growing trend toward structured electronic data exchanges as well as transactional standards and payer-specific workflows. These are developments to keep an eye on for practices considering any expansion of revenue cycle technology, as eligibility verification is becoming part of a growing system of electronic payer-provider data exchange. X12 270/271 is still

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Electronic Prior Authorization: How It Works and Why It Matters

Medical Billing

A patient needs an MRI. Under the old process, the request goes out by fax or gets entered into a payer’s proprietary web portal, a staff member checks back days later, and if it’s denied, the reason is often a vague code that doesn’t explain what would actually satisfy the payer. Electronic prior authorization is built to close that gap: the request, the supporting clinical data, and the payer’s decision all move through a standardized, machine-readable format instead of a document sitting in a fax queue. Electronic prior authorization (ePA) replaces fax forms, phone calls, and payer portals with structured data exchange, so a provider’s EHR can send a prior authorization request directly to a payer’s system and receive a response through a standardized API instead of a manual back-and-forth. CMS finalized rules requiring many payers to support this for medical items and services starting in 2026, and a 2026 proposed rule would extend similar requirements to prescription drugs. The result, when it works as designed, is faster decisions, clearer denial reasons, and less administrative time spent chasing down authorizations. How Electronic Prior Authorization Actually Works At the technical level, ePA runs on HL7 FHIR-based APIs, a standardized way for different health IT systems to exchange structured data rather than PDFs or free text. Instead of a staff member manually re-entering information into a payer portal, a provider’s EHR can query the payer’s system to check whether a service requires prior authorization, submit the request with the relevant clinical documentation attached, and receive a decision back in a format the EHR can read directly. This is different from older electronic submission methods that some practices already use, like the X12 278 transaction standard. CMS has specifically stated it will not pursue enforcement action against covered entities that use FHIR-based prior authorization APIs instead of X12 278, effectively signaling that FHIR is the direction the industry is expected to move toward. The Regulatory Push Behind the 2026 Deadlines Electronic prior authorization isn’t just a vendor feature practices can opt into. It’s being driven by federal rulemaking on a specific timeline. CMS finalized the CMS Interoperability and Prior Authorization rule in early 2024, requiring impacted payers, including Medicare Advantage organizations, Medicaid and CHIP fee-for-service and managed care plans, and Qualified Health Plan issuers on the federal exchanges, to implement a Prior Authorization API, provide specific reasons for denials, publicly report prior authorization metrics, and shorten decision timeframes. Certain provisions of that rule took effect January 1, 2026, with the full API requirements primarily due by January 1, 2027. CMS has estimated these combined policies could produce roughly 15 billion dollars in savings over ten years, largely from reduced administrative burden across the healthcare system. It’s worth being clear about scope here: these requirements apply to the specific payer categories listed above. Traditional, original Medicare fee-for-service and most employer-sponsored commercial plans outside the ACA marketplace are not covered by this particular rule, which matters when a practice is trying to figure out which of its payers are actually obligated to move to ePA and on what timeline. 2026 Expansion: Electronic Prior Authorization for Drugs The 2024 rule focused on non-drug items and services. On April 10, 2026, CMS released a proposed rule, the 2026 CMS Interoperability Standards and Prior Authorization for Drugs rule, that would extend similar electronic prior authorization requirements specifically to prescription drugs. The proposal would require impacted payers to support electronic prior authorization for drug coverage requests, meet shorter and more consistent decision timeframes, and increase transparency around drug-specific denials, an area providers have long flagged as particularly opaque, since denial communications for medications have often relied on vague or payer-specific language that makes it hard to know what would actually get a request approved on resubmission. As a proposed rule, this wasn’t finalized as of this writing. The public comment period ran until June 15, 2026, and if finalized as proposed, most provisions would take effect October 1, 2027. Practices should treat the drug-specific expansion as a signal of where things are headed rather than an active requirement yet. Why This Matters Beyond Compliance The administrative burden argument for ePA is real, but the more immediate impact for most practices is turnaround time and clarity. A structured electronic request that a payer’s system can process automatically, or route more efficiently to the right reviewer, tends to move faster than a fax sitting in a queue behind hundreds of others. The denial transparency requirement matters just as much: a specific, structured reason for a denial gives a practice something concrete to act on, rather than a generic code that requires a phone call just to understand what happened. A Quick Readiness Checklist Area What to Confirm EHR and practice management system Confirm current or planned support for FHIR-based prior authorization APIs Payer mix Identify which of your payers fall under the CMS Interoperability and Prior Authorization rule and their specific compliance timeline Staff workflow Update prior authorization workflows to route eligible requests through electronic channels instead of fax or portal entry Denial tracking Build a process to capture and act on the more specific denial reasons the new rules require Drug-specific PA Monitor the 2026 proposed rule’s status, since it is not yet finalized and timelines could shift Conclusion Getting prior authorization workflows ready for these deadlines is as much an operational question as a technical one, since it touches eligibility verification, payer-specific tracking, and denial follow-up all at once. Rapid RCM Solutions supports that kind of operational readiness through its eligibility and benefits verification, coding, and reporting services, helping practices track which payers require what and follow up efficiently when a request stalls. You can learn more at rapidrcmsolutions.com.

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OIG Medical Billing Audit Risks: What Healthcare Providers Need to Know

Medical Billing

A practice bills an E/M visit on the same day as a minor procedure. The claim is paid without modifier 25, even though the E/M service may have been significant and separately identifiable. That type of billing pattern is specifically part of OIG’s 2026 work plan. If the documentation doesn’t support a significant and separately identifiable E/M service, the claim may present a compliance risk. OIG’s 2026 work plan specifically includes a review of E/M services performed on the same day as minor surgery when modifier 25 was not appended. That’s one example of the type of billing issue reflected in OIG’s 2026 work plan. It’s rarely about obscure or unusual billing. It’s about a handful of specific, well-known risk areas where OIG has explicitly said it’s looking and where the gap between what a provider believes is defensible and what the documentation actually proves tends to be widest. Why Is Modifier 25 an OIG Medical Billing Audit Risk in 2026? In March 2026, OIG announced a work plan project examining E/M services performed on the same day as minor surgery when modifier 25 was not appended. OIG said it would determine whether Medicare Administrative Contractors’ processing and payment of those claims complied with Medicare requirements. Modifier 25 has also been the subject of previous OIG reviews. OIG’s earlier work found significant compliance problems in certain E/M claims billed with modifier 25, including claims for E/M services provided on the same day as intravitreal injections. When modifier 25 is reported, the medical record must support a significant, separately identifiable E/M service performed on the same day as the procedure. Chronic Care Management Billing Is Under Direct Review Medicare has paid for chronic care management (CCM) services since 2015, and utilization grew substantially through the following years. That increase is part of the context for OIG’s 2026 review. In March 2026, OIG announced a review of Medicare Part B CCM payments that may not comply with the requirement that patients have two or more qualifying chronic conditions. The conditions must be expected to last at least 12 months, or until the patient’s death, and must place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. Practices billing CCM codes need documentation that clearly establishes both qualifying conditions, the required monthly non-face-to-face time, and a documented care plan. Billing CCM based on a general sense that a patient is medically complex, without the specific qualifying conditions and time clearly logged, is precisely the pattern this review is designed to catch. Why Does Medicare Advantage Diagnosis Coding Keep Drawing Scrutiny? OIG continues to scrutinize diagnosis codes submitted for Medicare Advantage risk adjustment, particularly diagnoses that aren’t clearly supported by current documentation. In a 2026 audit of Priority Health, OIG found that medical records did not support the diagnosis codes for 252 of 300 sampled enrollee-years, resulting in $828,010 in net overpayments. Based on those sample results, OIG estimated that Priority Health received at least $4.4 million in net overpayments for 2018 and 2019. Medicare Advantage organizations submit diagnosis codes to CMS for risk adjustment, and those diagnoses must be supported by the medical records. Providers therefore play an important role by documenting the conditions evaluated and managed during the encounter rather than simply carrying unsupported diagnoses forward. A diagnosis carried forward without supporting documentation from the current service year can create significant compliance risk, and this remains one of the more active areas of federal review heading into the back half of 2026. Predictive Data Analytics Are Changing How Audits Get Triggered Claims data and other analytics can help federal agencies and Medicare contractors identify unusual billing patterns for further review. For providers, that makes internal monitoring of coding and utilization patterns an important part of compliance. The Overpayment Obligation Doesn’t Disappear After the Audit When a Medicare overpayment is identified, providers and suppliers generally have an obligation to investigate, report, and return it. For Medicare Parts A and B, CMS requires self-identified overpayments to be reported and returned by the later of 60 days after identification or the applicable cost-report due date, subject to applicable rules and exceptions. Detected but uncorrected billing issues carry more risk than an honest, promptly corrected mistake. Compliance programs that lack a clear, documented process for identifying and returning overpayments are themselves a compliance gap OIG has flagged as a concern. A Quick Preparation Checklist Risk Area What to Confirm E/M + minor procedure claims Documentation supports whether a separately identifiable E/M service was performed, and modifier 25 is reported when applicable CCM billing Two or more qualifying chronic conditions, monthly time, and a care plan are all documented MA diagnosis coding Submitted diagnoses are supported by the medical record and meet applicable risk-adjustment requirements Billing pattern review Internal audits compare billing volume and code selection against specialty norms Overpayment handling A documented process exists for identifying, investigating, and returning overpayments within required timeframes The Real Question Every Practice Should Ask OIG’s 2026 work plan gives providers and healthcare organizations a clearer picture of several billing and documentation risks receiving federal scrutiny: a modifier with a long audit history, a care management code tied to a strict eligibility requirement, and Medicare Advantage risk-adjustment diagnoses under continued federal scrutiny. For healthcare providers, the practical takeaway isn’t to predict every future audit. It’s to understand the documentation and billing requirements behind the areas OIG is reviewing and strengthen internal controls accordingly. Rapid RCM Solutions supports healthcare organizations by enhancing billing oversight by providing coding, charge entry, and reporting assistance, allowing them to detect any documentation and coding concerns before the claim is made. For more information on Rapid RCM Solutions’ medical billing support approach, check out rapidrcmsolutions.com.

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HCC Coding and Revenue Cycle Management: How They Work Together

Medical Billing

Most revenue cycle conversations focus on the claim in front of you: is it coded right, will it get paid, and if it’s denied, how fast can it get fixed? HCC coding runs on a different timeline entirely. A diagnosis captured or missed during an encounter can affect the risk adjustment data used for the applicable measurement year, even though the original claim may have been closed months earlier, and it can get pulled into an audit two or three years later, long after the claim itself has been closed and forgotten. That mismatch is exactly why HCC coding and revenue cycle management have to work as one connected system rather than two separate departments. A coding team that captures every relevant diagnosis but doesn’t feed that information into the RCM workflow in time is leaving revenue on the table. An RCM team that processes claims efficiently but doesn’t understand how HCC documentation holds up over time is building revenue on a foundation that can be revised later. Where HCC Coding Fits Into the Revenue Cycle Revenue cycle management typically runs through a familiar sequence: eligibility verification, documentation and coding, charge entry, claims submission, payment posting, denial management, and accounts receivable follow-up. HCC coding interacts with the revenue cycle differently from traditional fee-for-service coding. At the front end, eligibility and enrollment information helps establish whether the patient and encounter fall within the applicable Medicare Advantage risk adjustment framework. In the middle of the cycle, clinical documentation and coding accuracy determine whether a chronic condition actually gets captured as an HCC, or quietly falls off the list because the note didn’t support it. On the back end, risk-adjustment-related payment does not behave like a standard claim that simply pays or denies. It may be affected by later data corrections, validation reviews, or audits, which means audit readiness can remain relevant long after a claim has been closed. HCC coding revenue cycle management works best when coding, documentation, reporting, and audit processes are connected rather than handled in isolation. Documentation Quality Is the Real Revenue Driver In fee-for-service billing, a coder can often work from a fairly complete note and select the right code. HCC coding depends on something more specific: documentation that shows a condition was actually addressed during the encounter, not just referenced from a past visit. Many coding teams use the MEAT framework (Monitor, Evaluate, Assess, or Treat) as a practical way to review whether documentation shows that a condition was addressed during the encounter. A diabetic diagnosis that simply remains on the problem list is not equivalent to documentation showing that the condition was addressed during the encounter. From an RCM standpoint, this means documentation quality isn’t just a compliance concern sitting off to the side. It’s directly tied to whether the diagnosis captured this year is defensible if it’s reviewed later. Annual Recapture Is a Revenue Cycle Problem, Not Just a Coding One Risk adjustment diagnoses generally need to be supported by current-year documentation and qualifying diagnosis data to contribute to that year’s risk score. For a condition to continue contributing, current-year documentation and coding usually need to support it again, even when nothing about the patient’s health has changed. This creates a specific kind of revenue leakage that traditional RCM metrics don’t always catch. A denied claim shows up immediately as a number on a report. A missed diagnosis capture shows up as a slowly declining RAF score across a patient panel, which is much easier to miss until it’s already affected the organization’s payment calculations for the year. Building recapture tracking into the RCM workflow gives teams a better opportunity to identify missing current-year diagnoses before the measurement year closes. The V28 Model Has Made Coordination More Important For 2026, CMS has completed the phase-in of the 2024 CMS-HCC model, commonly called V28, for Medicare Advantage organizations other than PACE, with 100% of the risk score calculated under the updated model for applicable Medicare Advantage organizations. This kind of model transition is exactly where the gap between coding teams and RCM teams tends to widen. A coding team that’s fully trained on V28’s updated condition groupings can still create problems downstream if the RCM workflow around it, including how coded diagnoses flow into downstream reporting and risk adjustment processes, hasn’t been updated to match. Keeping both sides of the operation on the same current model, rather than letting coding update faster than the systems and workflows around it, is one of the more overlooked coordination points in 2026. Audit Defense Depends on RCM Infrastructure, Not Just Coding Accuracy When a Risk Adjustment Data Validation (RADV) audit or OIG review examines a sample of medical records, the organization needs to reconstruct exactly why a specific diagnosis was coded for a specific encounter, potentially long after the original encounter. That’s an RCM infrastructure problem as much as a coding one. Organizations that store coding rationale, MEAT documentation references, and encounter-level detail in a way that’s easy to retrieve tend to defend audits far more efficiently than organizations relying on staff memory or scattered records to reconstruct the reasoning after the fact. A Quick Coordination Checklist Stage What to Confirm Eligibility verification Medicare Advantage enrollment status is current before coding decisions are made Documentation and coding Notes support MEAT elements for every HCC-relevant diagnosis reported Charge entry and claims Coded diagnoses flow into claims and reporting systems without delay Annual recapture Active chronic conditions are re-documented and re-coded each calendar year, not assumed to carry forward Model updates Coding and RCM systems both reflect the current CMS-HCC model version Audit readiness Coding rationale and supporting documentation are stored in a retrievable format, not just in staff memory Conclusion None of this requires a complicated overhaul. It requires coding and RCM functions that actually talk to each other: documentation reviewed for MEAT support before it’s coded, coded diagnoses that flow into claims and reporting without delay, and a recapture cycle that runs every year instead of getting rediscovered

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Risk Adjustment Coding Challenges: Common Problems and How to Solve Them

Medical Billing

A chart shows a patient with diabetes, chronic kidney disease, and congestive heart failure. All three conditions are documented in the patient’s history, but the note for this particular visit clearly shows active management of only two of them. The diagnosis itself may be accurate. The problem is that the current medical record does not provide enough support for reporting it for risk adjustment purposes that year. A true diagnosis with weak supporting documentation and an inaccurate diagnosis can both fail a review for the same underlying reason: the chart doesn’t back up the code. This is what makes risk adjustment coding harder than most people expect going in. It’s less about knowing which ICD-10 code maps to which HCC category, and more about building documentation habits precise enough to survive a review that happens months or years after the visit. How MEAT Helps Coders Evaluate HCC Documentation MEAT (Monitor, Evaluate, Assess, or Treat) is a commonly used framework for reviewing whether documentation shows that a reportable condition was addressed during the encounter, rather than simply carried forward on a list. A condition listed on a problem list without any of those four elements documented for the current encounter is generally not a strong candidate for risk adjustment coding, regardless of how clinically real the condition is. This trips up practices constantly because it’s easy to assume that referencing a condition is the same as documenting it. Reviewing recent labs tied to kidney function, adjusting a medication dose for heart failure, or evaluating a diabetic patient’s neuropathy symptoms during the visit all support MEAT. Simply carrying a diagnosis forward on the problem list, with no visible connection to what happened during that specific encounter, does not. Coding Historical Conditions as Active This is one of the most consistently flagged errors in recent federal audits, and it’s a genuinely easy mistake to make: a condition that resolved in the past gets coded as if it’s still active. A stroke from several years ago gets submitted as an acute stroke. A cancer that was treated and resolved gets coded as a current malignancy. The scale of this problem became public in a notable way in 2026. In one OIG audit, none of the high-risk acute stroke diagnosis codes submitted for the 97 sampled enrollees were supported by the associated medical records. Based on those findings, OIG estimated approximately 462 million dollars in potential net overpayments to Medicare Advantage organizations for 2021. That’s a documented pattern serious enough to draw federal scrutiny, and stroke and myocardial infarction diagnoses have been particularly prone to this history-versus-active confusion because the acute event and its long-term aftermath often get described in similar language in the chart. The fix is a coding habit, not a coding rule: confirm whether a condition is currently active and being managed, or whether it’s a historical event with lingering effects, before assigning a code that implies it’s still acute. Hierarchy Suppression Errors HCC models are built around hierarchies, where a more severe version of a condition suppresses payment for a less severe version of the same condition. When conditions fall within the same HCC hierarchy, the more severe category can supersede the less severe category in the risk score calculation. Coders therefore need to understand the hierarchy rather than assuming that reporting every historical severity level will increase risk adjustment value. This isn’t really a documentation problem so much as a coding logic problem: understanding which conditions in a patient’s chart interact hierarchically, and coding to the correct, single, most specific level rather than layering in every version of a diagnosis that’s ever appeared in the record. Why Do HCCs Need Annual Recapture? HCCs don’t roll over automatically from one year to the next. For diagnoses that are relevant to the applicable risk adjustment model, conditions generally need current-year documentation and qualifying diagnosis data to be captured for that year’s risk score, even if nothing about the patient’s condition has changed. A diabetic patient managed consistently for the past five years still needs that diagnosis reflected in this year’s documentation, not just referenced as an ongoing historical fact. Practices that don’t build recapture into their annual workflow tend to see RAF scores drift downward over time, not because patients are getting healthier, but because conditions that are still very much present simply aren’t being re-documented on schedule. Defaulting to Unspecified Codes When documentation supports a specific diagnosis but the coder (or the EHR’s suggested code) defaults to an unspecified version instead, that unspecified code may fail to map to a payable HCC at all, or it may provide less risk-adjustment value than a more specific code the documentation actually supports. This tends to happen under time pressure, when a specific code requires a bit more digging through the note than an unspecified one does. CMS-HCC V28 Is Fully Phased In for 2026 For CY 2026, CMS has completed the phase-in of the 2024 CMS-HCC model, commonly referred to as V28, for Medicare Advantage organizations other than PACE. CMS now calculates 100% of the risk score using this updated model, which replaced the prior model’s condition groupings and weights. Coders and practices still working from older reference materials or habits built around the previous model’s category structure risk misclassifying conditions that were regrouped or reweighted under V28. Keeping coding references current with the active model, rather than relying on training or cheat sheets that predate the phase-in, matters more this year than in a typical year specifically because of that changeover. It’s worth noting V28 applies to Medicare Advantage; other programs, including ACOs and PACE, work under their own applicable risk adjustment models. A Quick Prevention Checklist Issue Prevention Habit Documentation doesn’t show the condition was addressed Confirm the note shows monitoring, evaluation, assessment, or treatment for the specific encounter, not just a problem list entry Historical conditions coded as active Verify current activity status before coding an acute or active version of a past condition Hierarchy-related coding errors Code to

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The Most Common Cardiology Claim Denials and How to Fix Them

Medical Billing

A patient comes in for a stress test to work up chest pain. The test is medically appropriate, well documented, and performed correctly. Three weeks later, the claim comes back denied, not because anything was wrong with the care, but because prior authorization was never confirmed before the test was scheduled. That single scenario captures most of what makes cardiology billing so denial-prone. The clinical work is often flawless. The paperwork trailing behind it is where things fall apart, and cardiology has more of that paperwork than most specialties: prior authorizations for high-cost imaging and procedures, multi-element documentation requirements for tests like echocardiograms, frequency limits on device monitoring, and modifier rules that shift depending on whether a service is professional, technical, or bundled with something else performed the same day. Here’s a look at where cardiology claims actually break down and what fixes each one. Prior Authorization Gaps This is consistently one of the leading causes of cardiology denials, and it shows up across nearly every high-cost service the specialty relies on: cardiac catheterizations, PCI procedures, advanced imaging, and even some stress tests depending on the payer. The frustrating part is that these denials rarely have anything to do with whether the procedure was appropriate. A cath lab procedure performed without a confirmed authorization on file gets denied regardless of how clinically justified it was. The fix has to happen before the procedure, not after: verifying authorization status as a hard stop in scheduling, not a step that happens in parallel with booking the patient. Incomplete Echocardiogram Documentation CPT 93306, commonly used for a complete transthoracic echocardiogram, requires documentation that supports the components represented by the code, including complete 2D echocardiography, spectral Doppler, and color flow Doppler, with or without M-mode recording. If the documentation doesn’t support the complete service reported, the claim may be denied, downcoded, or require correction. Repeat echocardiograms may receive additional scrutiny, particularly when performed within payer-specific frequency limits. Documentation should clearly establish the medical necessity for the repeat study based on the patient’s condition, symptoms, treatment plan, or other applicable clinical indications. Modifier Errors on Complex Procedures Cardiology billing depends heavily on getting modifiers right, and a few specific mix-ups account for a large share of the denials in this category: These aren’t one-off mistakes most of the time. Once a modifier error gets built into a billing template, it repeats on every claim that runs through it, which is why regular modifier-focused audits catch far more than reviewing denials one at a time. Bundling Errors Between Related Services Certain cardiology services are bundled by definition or subject to NCCI edits and should not be separately reported unless the applicable coding rules allow separate reporting. For example, CPT 93351 for stress echocardiography includes the stress-test components represented by the code, so separately reporting overlapping services can result in a bundling denial. Similarly, CPT 93306 includes spectral Doppler and color flow Doppler as part of the complete echocardiographic service, so separately reporting Doppler services already included in 93306 would duplicate components of the primary service. Separate reporting may be appropriate in other situations when an additional diagnostic service is genuinely distinct, medically necessary, and separately documented. Depending on the specific code pair and applicable NCCI edit, modifier 59 or a more specific X{EPSU} modifier may be appropriate when the requirements for separate reporting are met. The key distinction is whether the additional service represents separate work or is already included in the primary code. Checking current NCCI edits and payer-specific policies before submission is the safest way to make that determination. Device Monitoring Frequency Denials Remote cardiac device monitoring (pacemakers, defibrillators, loop recorders) comes with built-in frequency limits, typically a 30- or 90-day minimum window depending on the device and service, and billing before that window has elapsed is a frequent, avoidable denial trigger. Confirming the monitoring interval against the specific device and payer policy before submitting the claim prevents a denial that has nothing to do with the quality of the monitoring itself. Medical Necessity and Diagnosis Specificity Stress tests are especially vulnerable here. Payers want to see documented symptoms and risk factors that clearly support why the test was ordered, not just a general cardiac history. A vague or unspecified diagnosis code attached to a stress test order is one of the more common reasons medical necessity gets challenged, even when the clinical reasoning behind the test was entirely sound. A Quick Prevention Checklist Issue Prevention Habit Prior authorization gaps Verify whether authorization is required and confirm it before applicable tests or procedures Incomplete echo documentation Confirm documentation supports all components required by the specific echocardiography code Repeat echo denials Document the clinical indication and medical necessity for repeat testing Modifier errors (26/TC, 59/X{EPSU}) Verify modifier use against the service performed, NCCI edits, and payer requirements Bundling conflicts Check current NCCI and payer-specific edits before separately reporting same-day services Device monitoring frequency denials Verify code-specific reporting periods and payer frequency requirements before billing Medical necessity gaps Use diagnosis coding and clinical documentation that accurately support the service performed Conclusion Almost every denial category above traces back to the same underlying issue: a gap between what actually happened clinically and what the claim, the note, or the authorization record shows on paper. The procedure was appropriate. The documentation just didn’t prove it clearly enough, or the authorization wasn’t confirmed before the patient walked in. Cardiology practices that keep denial rates manageable aren’t necessarily the ones with the most detailed coding knowledge. They’re the ones who’ve built verification into the workflow itself: authorization checks before scheduling, documentation templates that prompt for the specific elements payers require, and periodic review of bundling and frequency rules that shift more often than most practices expect.

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Orthopedic Surgery Coding Guidelines: Common Mistakes to Avoid

Medical Billing

A patient comes in six weeks after a total knee replacement with new pain in the opposite knee, unrelated to the surgery and clearly documented as such in the note. Should that visit be billed separately, or does it fall inside the global period and get absorbed into the original procedure’s payment? Get that call wrong in either direction, and it costs the practice money. Bill it separately without the right modifier, and the claim gets denied for falling inside the global window. Fail to bill it at all, assuming everything in that window is automatically bundled, and the practice quietly writes off a legitimately billable visit. This is the shape of most orthopedic coding problems: not a mystery code nobody’s heard of, but a routine judgment call that depends on the specific circumstances of the visit and whether the documentation actually supports the distinction being made. Orthopedic practices move through evaluation visits, imaging, injections, fracture care, arthroscopy, and joint replacement in the same week, and each category carries its own rules for modifiers, bundling, and medical necessity. The codes themselves aren’t usually the hard part. Knowing which rule applies to which visit and proving it in the chart is. Global Period Billing Mistakes Run in Both Directions Many major orthopedic procedures have a 90-day global period, during which routine postoperative care related to the surgery is generally included in the original procedure’s payment. The mistake most people picture is billing a routine post-op visit inside that window as if it were a new encounter. That’s real, and payers’ AI-assisted claim review tools are increasingly good at flagging it. The less-discussed version can cost practices just as much: failing to bill for care that is genuinely separate from the original procedure but happens to occur during the global period. An unrelated E/M service may require modifier 24, while staged, related, or unrelated procedures during the postoperative period may require modifiers such as 58, 78, or 79, depending on the circumstances. Documentation must clearly establish why the service is separately reportable rather than part of routine postoperative care. Modifier Errors Are the Most Repeated Mistake in the Specialty Modifier issues show up across nearly every category of orthopedic coding, and the reason they’re so persistent is structural: once a wrong modifier pattern gets built into a billing template, every claim that runs through that template repeats the same error. A few of the most common- laterality modifiers (LT/RT) applied inconsistently or omitted entirely on bilateral-capable procedures; modifier 59 (or the more specific X{EPSU} modifiers) used to separate procedures that NCCI edits would otherwise bundle, without documentation that actually supports two distinct procedures; and modifiers 78 and 79 confused with each other during a global period; 78 covers a related procedure requiring a return to the operating room, while 79 covers one that’s genuinely unrelated. Mixing these up doesn’t just cause a denial; it can look like a billing pattern under audit, which is a bigger problem than any single claim. NCCI Bundling Edits Trip Up Multi-Procedure Visits Orthopedic visits frequently involve more than one procedure in the same session: an arthroscopic debridement alongside a more extensive repair, for instance, and the National Correct Coding Initiative maintains edits that bundle certain code pairs together by default. Reporting both codes separately without checking whether an edit applies, or without the modifier needed to justify separate reporting when it’s genuinely warranted, is one of the more common and avoidable sources of automatic claim reductions. Checking current NCCI edit pairs before submission, rather than relying on what worked last year, is the practical fix; these edits are updated regularly and don’t stay static. Documentation Gaps: Injections, Imaging Guidance, and Fracture Specificity A few documentation patterns show up repeatedly across orthopedic denials. Injection procedures are billed with ultrasound guidance codes when the note only supports a standard “blind” injection: the guidance code needs its own explicit documentation, not an assumption based on how the practice usually performs the procedure. Fracture care coding needs enough specificity to reflect the actual fracture type, site, and treatment approach (open versus closed treatment, with or without manipulation) rather than defaulting to a general code that doesn’t fully capture what was done. And operative notes that describe the procedure narratively without clearly identifying the specific anatomical structures addressed make it difficult for a coder or an auditor to confirm the code selected actually matches the work performed. Medical Necessity and Prior Authorization for High-Cost Procedures Even a correctly selected CPT code can fail if the diagnosis code attached to it doesn’t clearly support medical necessity for that specific service. This matters most for higher-cost orthopedic procedures like joint replacements, spine surgery, and advanced imaging, which frequently require prior authorization before the procedure happens at all. Confirming both the authorization and the diagnosis-to-procedure linkage before surgery, rather than after the claim is submitted, prevents a denial that has nothing to do with how well the procedure itself was coded. A Quick Prevention Checklist Issue Prevention Habit Global period billing errors Confirm whether a visit is a routine follow-up or genuinely separate before choosing a modifier Modifier errors (LT/RT, 59, 78, 79) Audit billing templates regularly, since one wrong pattern repeats across every claim that uses it NCCI bundling conflicts Check current NCCI edit pairs before submitting multi-procedure claims Injection/imaging guidance documentation Confirm ultrasound or fluoroscopic guidance is explicitly documented, not assumed Fracture coding specificity Document fracture type, site, and treatment approach clearly in the note Medical necessity mismatches Confirm the diagnosis code supports the specific procedure billed Prior authorization gaps Verify authorization for high-cost procedures before the surgery date Conclusion Almost none of these mistakes come down to simply not knowing the codes. They usually happen during routine decisions: Is this service included in the global period or separately reportable? Does the documentation support this modifier? Does the diagnosis establish medical necessity for the procedure? When these decisions are made repeatedly without a consistent review process, one small mistake can quickly

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Pediatric Billing Denial Reasons: Common Causes and How to Prevent Them

Medical Billing

A 5-year-old comes in for a routine well-child visit. Growth chart, developmental screening, three scheduled vaccines. A straightforward preventive appointment. Then the parent mentions a cough that’s been lingering for a week. The physician evaluates it, notices some wheezing, and addresses the problem during the same encounter. One appointment, with potentially several separately reportable components: the preventive exam, a problem-oriented E/M service for the wheezing, developmental screening, and vaccine administration. Each one follows its own rules for coding, documentation, and modifier use, and if any single piece doesn’t line up, that’s often enough to send the claim into denial. This is what makes pediatric billing genuinely harder than a lot of other specialties. It’s not that the codes are more obscure. It’s that a single pediatric visit can involve several potentially billable services within the same encounter, and payers are quick to reject claims when those services aren’t clearly distinguished in the documentation. Missing Modifier 25 on Combined Preventive and Sick Visits This is one of the most common denial triggers in pediatric billing, and it shows up constantly for exactly the reason described above: a well-child visit that turns into a sick visit partway through. Modifier 25 is appended to the problem-oriented E/M code when the physician or other qualified healthcare professional provides a significant, separately identifiable E/M service beyond the work normally included in the preventive visit. The problem doesn’t necessarily have to be new or acute. A chronic condition addressed beyond the scope of the preventive service may also support a separately reportable E/M service when the documentation supports it. If a child is in for a well visit and the physician also diagnoses and treats an ear infection, the additional work may support a separate problem-oriented E/M code with modifier 25 when the documentation supports it; the preventive code alone doesn’t capture that work. Denials happen when the note blends the two together instead of documenting them as distinct components. If a reviewer can’t tell where the preventive exam ends and the sick-visit evaluation begins, the claim doesn’t have anything solid to justify billing both. Vaccine Billing Errors Vaccines are their own denial category entirely, and the mistakes here tend to repeat in predictable ways. A common vaccine billing problem is failing to report the appropriate vaccine product and administration information according to the payer’s and program’s requirements. For privately purchased vaccines, reimbursement may involve both the vaccine product and the applicable administration service; leaving one off can mean incomplete reimbursement for a service that was fully performed. Vaccines for Children (VFC)-supplied vaccines follow different billing requirements, since the vaccine itself is provided through the program rather than purchased and billed as a product by the practice. Practices also need to select the appropriate administration code based on factors such as the patient’s age, whether qualified counseling was provided, the route of administration, and payer requirements. Beyond that, incomplete or inconsistent VFC documentation, such as missing lot numbers, incorrect program indicators, or improper linkage between the vaccine and administration code, can create billing, reconciliation, and program-compliance problems even when the rest of the claim is accurate. It’s also worth remembering that VFC documentation isn’t purely about claim reimbursement; some of it exists for program compliance and inventory accountability, independent of whether a specific claim gets paid. Developmental Screening Documentation Gaps When reporting CPT 96110 for standardized developmental screening, documentation should clearly support that a standardized instrument was administered and scored; not just that a screening “happened.” Practices should also document the specific tool used, the results or score, and relevant follow-up or interpretation, in accordance with payer and documentation requirements. A practice using a standardized tool consistently but skipping the interpretation piece is a frequent, avoidable cause of denial for this code specifically. Coordination of Benefits and Coverage Churn Insurance coverage changes can create significant denial risk in pediatric billing, even when the clinical coding itself is correct. Two scenarios show up constantly. First, when a child is covered by both parents’ health plans, the correct primary and secondary payer must be established using the applicable coordination-of-benefits rules; get the payer order wrong, and a clean claim gets denied before anyone even reviews the coding. In many situations involving both parents, the “birthday rule” is what determines primary coverage: whichever parent’s birthday falls earlier in the calendar year typically has the primary plan, though exceptions apply depending on the specific plans and circumstances involved. Second, pediatric coverage can change during the year because of employment changes, Medicaid or CHIP eligibility updates, plan renewals, or other family circumstances; a child covered by Medicaid one month might be on CHIP or a commercial plan the next. Eligibility verification that isn’t re-checked at every visit is a quiet, recurring source of denials that has nothing to do with what the physician actually did in the room. Basic Demographic and Eligibility Errors It sounds too simple to matter, but demographic mismatches are a genuinely common source of pediatric claim rejections: misspelled names, a date-of-birth typo, or a gender field that doesn’t match what’s on file with the insurer. These are rejections rather than true denials in the technical sense (the claim bounces back before the payer even reviews it clinically), but they still delay payment and add rework for staff. Verifying demographic and insurance information at each visit is one of the simplest ways to prevent these avoidable rejections. Prior Authorization Requirements That Shift by Payer Certain pediatric services, medications, diagnostic studies, specialty referrals, therapies, and behavioral health services may be subject to prior authorization or referral requirements depending on the patient’s specific plan, and those requirements aren’t static. They change by plan and by renewal period, which means an authorization workflow that worked fine six months ago can quietly become outdated. Because requirements vary by payer and plan, practices shouldn’t assume that an authorization rule that applied to one patient, or in one benefit year, will automatically apply to another. Age-Specific Code Selection Errors Preventive medicine codes are

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Urgent Care Billing Modifiers: A Practical Guide for Accurate Claims

Medical Billing

A patient walks in with a two-inch laceration on their forearm. While the provider is cleaning and prepping it for repair, they notice the patient looks pale and mentions some chest tightness, and the visit turns into something bigger: vitals, an EKG, and a real evaluation before anyone touches a suture. That’s two services in one visit: a procedure and a genuinely separate evaluation and management encounter. Bill it wrong, and the payer bundles the E/M into the procedure fee, treating that extra workup as if it never happened. Bill it right, with the correct modifier and documentation to back it up, and the claim reflects what actually happened in the room. This is the entire modifier problem in urgent care, condensed into one visit. Procedures and E/M services collide constantly here: laceration repairs, injections, wound care, on-site testing, and the modifiers exist specifically to tell the payer which parts of the visit are separate and billable versus which parts are just part of the procedure itself. Get that distinction wrong often enough, and it stops looking like an occasional mistake and starts looking like a pattern the payer flags for review. Modifier 25: The One You’ll Use Constantly If there’s a single modifier that defines urgent care billing, it’s this one. Modifier 25 is appended to an E/M service when a significant, separately identifiable evaluation and management service is performed by the same physician or other qualified healthcare professional on the same day as another procedure or service. The laceration-and-chest-tightness example above is the textbook case; the provider did real diagnostic work that had nothing to do with closing the wound. Where this goes wrong, consistently, is the opposite scenario: a quick visual check, a brief assessment, then straight into the procedure, and the E/M gets billed with modifier 25 anyway because that’s just the habit. Payers catch this pattern fast, and it’s one of the more reliable ways to trigger an audit rather than a one-off denial. The fix isn’t complicated; it’s just discipline: document the E/M and the procedure as two distinct sections of the note, not one blended narrative. If a reviewer can’t clearly see where the evaluation ends and the procedure begins, modifier 25 doesn’t have anything solid to stand on. Note: The E/M service does not necessarily need a different diagnosis from the procedure, but the documentation must show that the evaluation went beyond the usual pre- and post-procedure work. Modifier 59: Separating Procedures That Look Bundled Modifier 59 comes into play when two procedures performed on the same day would normally be bundled together under standard payer edits but were actually distinct: different sites, different sessions, or genuinely separate procedures that just happened to occur during the same visit. This one gets less airtime than modifier 25, but it matters anywhere urgent care volume includes multiple procedures in a single encounter; say, an incision and drainage plus a separate laceration repair at a different site. Without modifier 59, the payer’s bundling edits may quietly fold one into the other, and the claim pays for less than what was actually done. Note: When applicable, check whether the payer prefers one of the more specific X{EPSU} modifiers instead of Modifier 59. Modifier 27: The One You’ll Rarely Need Modifier 27 indicates multiple outpatient hospital E/M encounters on the same date. It exists, and it’s technically part of the same modifier family as 25, but it’s built for hospital outpatient billing scenarios, not the typical freestanding urgent care visit. Most urgent care coders will go long stretches without touching it. Worth knowing it exists so it doesn’t get confused with modifier 25 during training, but not something to build a workflow around. The S9083 Decision: Modifier Logic Doesn’t Apply the Same Way Everywhere Not every urgent care claim runs through standard E/M coding. Many commercial and Medicaid plans use S9083, a flat global per-visit fee, instead of itemized E/M billing; while Medicare doesn’t recognize S-codes at all and pays standard E/M codes regardless. This matters for modifier strategy because it’s not a coding choice; it’s a payer-contract choice. Submitting E/M codes with modifiers to a payer that requires the S9083 global fee (or the reverse) is a fully preventable denial that has nothing to do with clinical documentation. The practical fix most billing teams land on is a payer reference grid, a simple internal document mapping which contracts require S9083 versus standard E/M, checked before the claim goes out, not after it bounces back. G2211: A Newer Add-On With a Specific Restriction G2211 is an add-on code designed to recognize the visit complexity associated with an ongoing practitioner-patient relationship or ongoing care related to a patient’s serious or complex condition. Because traditional urgent care is often episodic rather than longitudinal, its use in urgent care requires careful review of whether the encounter actually meets the applicable requirements. The restriction worth knowing: G2211 is still generally not payable on a claim where modifier 25 is also billed for a same-day procedure; that part of the original rule stands. But CMS carved out an exception effective 2025: if the modifier-25 service is one of CMS’s listed Part B preventive services (like an Annual Wellness Visit or vaccine administration), G2211 can be paid alongside it, provided your documentation independently supports the longitudinal-care rationale; modifier 25 being present doesn’t automatically qualify the visit. This is a rule that’s been revised three times since G2211 launched in 2024, so it’s worth confirming the current exception list against your MAC’s guidance rather than assuming last year’s rule still applies. A Regulatory Detail Worth Building Into Your Workflow It’s not a modifier, but it belongs in the same conversation: the No Surprises Act requires urgent care centers to provide a Good Faith Estimate to uninsured and self-pay patients (anyone without coverage, or anyone with coverage who simply isn’t using it for that visit) This isn’t a documentation nuance buried in a chart; it’s a front-desk workflow requirement, and centers that haven’t built

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Urgent Care Billing Modifiers: A Practical Guide for Accurate Claims

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